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Seth Wenig, Associated Press
FILE - This Wednesday, March 27, 2019 file photo shows a sign explaining the local state of emergency because of a measles outbreak at the Rockland County Health Department in Pomona, N.Y. Measles is spread through the air when an infected person coughs or sneezes. It's so contagious that 90 percent of people who aren't immunized are infected if exposed to the virus, according to the Centers for Disease Control and Prevention.

SALT LAKE CITY — More parents nationwide are seeking exemptions to states' requirements that students be vaccinated to attend school.

At the same time, nearly 400 cases of measles across 15 states have been reported just during the first quarter of 2019, according to the Centers for Disease Control and Prevention.

Public health officials believe these two facts are related.

Measles cases have been reported so far this year in Arizona, California, Colorado, Connecticut, Georgia, Illinois, Kentucky, Michigan, Missouri, New Hampshire, New Jersey, New York, Oregon, Texas and Washington, the CDC reported.

"In 2000, the CDC had stated that measles was eliminated from the United States," said Rich Lakin, immunization program manager in the Utah Department of Health. "People in other places got them, but CDC said we just don't see cases of measles anymore. Fast forward to 2019, we see them all the time. And there's a strong correlation between the increase in exemptions and measles outbreaks," he said.

Now some individual communities and state governments are trying to rein in what they see as vaccine exemptions run amok. Leaders of the American Academy of Pediatrics declared "elimination of non-medical exemptions to vaccination" a top priority during a recent leadership forum. Non-medical exemptions include those based on religious or personal beliefs about vaccinations, for example.

California has already done away with all but medical exemptions to vaccination rules.

Among local communities, New York City has taken the most recent and dramatic action, announcing mandatory measles vaccination in certain zip codes in Brooklyn, where 285 cases of measles have been confirmed since the fall — including 21 hospitalizations, five of them in intensive care, according to The New York Times.

The action follows a late March declaration by Rockland County, New York, officials barring all unvaccinated minors from public places. Parents "could face fines and possible jail time," WABC reported. Officials there have reported that, so far, more than 500 unvaccinated youths have received their shots since the late March ban was announced.

And last week, an unvaccinated Kentucky teen lost a lawsuit against his school, which has been experiencing a chickenpox outbreak and declared students could not go to school or play sports unless they could prove immunity to chickenpox by showing they had the disease already or they were vaccinated.

Grounds for exemption

Exemptions from state vaccination mandates — and who can get them — vary widely from place to place.

Every state requires students to be vaccinated, according to The National Conference of State Legislatures' summary on vaccination exemptions, updated at the end of January. But all states make an exception if a child has a medical condition that would make vaccination dangerous. Nearly all provide religious exemptions. And 17 states allows parents to opt their children out due to "philosophical" reasons. Sometimes the latter two are lumped together as "non-medical exemptions."

Most states require a medical exemption be documented by a licensed health care provider.

Julie Jacobson, Associated Press
An Orthodox Jewish man walks through the parking lot of a supermarket, Tuesday, March 26, 2019, in Spring Valley, N.Y. Rockland County in New York City's northern suburbs declared a state of emergency Tuesday over a measles outbreak that has infected more than 150 people since last fall, hoping a ban against unvaccinated children in public places wakes their parents to the seriousness of the problem. Rockland's outbreak has most heavily affected Orthodox Jewish communities, in which vaccination rates tend to be lower.

Religious exemptions, where allowed, typically rely solely on the statement of the parent that their religious beliefs do not allow vaccination. But when the Deseret News did a wide-ranging search for religions that formally prohibit exemptions a few years ago, it found just one religion that explicitly objects to vaccination. Many religions have members, though, that choose not to vaccinate.

The article "identified one faith, with approximately 12,000 members, that has a tenet explicitly rejecting injections or vaccines of any kind." That faith was the Congregation of Universal Wisdom, founded in New Jersey.

The Johns Hopkins University vaccine safety site notes that in 1995, the Islamic Organization for Medical Sciences wrote that gelatin contained in vaccines is deemed "judicially pure" although derived from pork products, so Muslims are not prevented by faith from getting required vaccines.

Some religious concerns have been raised because vaccines may use two human cell lines originally derived from fetuses aborted in the 1960s. The Catholic Church has said that "danger to the health of children" could permit parents to use a vaccine developed with those cell lines. And the Christian Medical and Dental Association said that "using technology developed from tissue of an intentionally aborted fetus, but without continuing the cell line from that fetus, may be morally acceptable."

In some states, exemption rules are adjusted periodically. Utah, for instance, two years ago began requiring parents to watch an online education video before applying online for an exemption.

Seth Wenig, Associated Press
FILE- In this March 27, 2019, file photo, measles, mumps and rubella vaccines sit in a cooler at the Rockland County Health Department in Pomona, N.Y. In social media’s battle against misinformation, bogus claims about the dangers of vaccines are the next target. With measles outbreaks wreaking havoc around the world, Facebook, Pinterest and others are trying to put the genie back in the bottle, even as they are hesitant, even unwilling to acknowledge outright responsibility for spreading falsehoods.

The rules vary a great deal. In Virginia, parents can get a personal exemption only for the HPV vaccine, but not others, the National Conference of State Legislatures said. And there's no personal belief exemption for those attending public schools in Missouri, though a child may be exempt from the child care facility vaccine requirement because of a parent's personal belief. Meanwhile, West Virginia requires a doctor certify personal exemption requests and Vermont in 2015 repealed its personal exemption statute entirely.

Only California, West Virginia and Mississippi do not allow religious exemptions, according to the council.

Utah allows religious, medical and personal exemptions. The vast majority claimed are personal exemptions, while religious exemptions account for fewer than 1 percent of exemptions in Utah.

Measles resurge

Measles is at the center of the current vaccine storm.

The disease is highly contagious — so much so, in fact, that one who is unvaccinated may get it practically by walking past someone who has the measles, said Dr. Paul Wirkus, president of the Utah chapter of the American Academy of Pediatrics. The early symptoms typically include high fever (104-degree range), cough, runny nose and watery eyes. After about three days, a rash appears.

The CDC reports most people with measles in America were not vaccinated, and it likely resurged here because someone traveled to a place the condition is more common and brought it back. Measles remains common in parts of Europe, Africa, Asia and the Pacific. Once here, it spreads "when it reaches a community in the U.S. where groups of people are unvaccinated."

When enough people in a population are vaccinated, the population achieves what public health officials call "herd immunity." A contagious disease doesn't spread if the share that has been immunized is high enough — about 95 percent in the case of measles, though it varies depending on the vaccine-preventable disease. Herd immunity provides some protection to people who can't be vaccinated, including young babies, people with compromised immune systems or certain medical conditions and pregnant women.

While most people who get measles will be miserable for a time and then recover, the disease sometimes kills, especially very young children. And individuals can suffer serious complications. A pregnant woman who gets measles, for example, may give birth too early or have low birth weight.

Mark Lennihan, Associated Press
A woman, right, who identified herself as Ester, passes a group of boys, Tuesday, April 9, 2019, in the Williamsburg section of Brooklyn, New York. Ester says that she does not believe that the measles vaccination is safe. The city health department ordered all ultra-Orthodox Jewish schools in a neighborhood of Brooklyn on Monday to exclude unvaccinated students from classes during the current measles outbreak. In issuing the order, the health department said that any yeshiva in Williamsburg that does not comply will face fines and possible closure.

CDC estimates that:

  • About 1 in 20 children with measles gets pneumonia, the most common cause of death from measles in young children.
  • One child of every 1,000 with measles suffers inflammation of the brain, leading potentially to seizures, intellectual disability or hearing loss.
  • For every 1,000 children with measles, one or two will die.

"CDC scientific facts are the gold standard for the world and we are fortunate to have them," said Lakin. "They say this is one of the 10 (top) public health threats. That means it's a big deal."

Warring factions

Those who support requiring immunizations and those who oppose it are increasingly vocal as vaccine-preventable diseases like measles seem to be surging. In addition to measles, mumps cases are on the rise, too. After it was hit by a mumps outbreak, Temple University recently announced that incoming students are going to have to have proof of MMR vaccination before they can attend any classes.

The Capitol building in Texas has been the site of competing vaccine-related rallies, including one in late March advocating choice in whether vaccines should be administered, and another April 2 in support of mandated vaccination requirements, the local Fox station reported.

The “vaccine by choice” rally was held to support two bills, one requiring requiring disclosure of any risks and explicit consent from a guardian and the other requiring release of any medical studies that evaluate "links to cancer, gene mutation, infertility and autism,” the report said.

Some people simply don't like to be told what to do by the government when it comes to their kids, but in other cases, opposition stems from a misguided belief that requiring vaccines exposes children to health risks.

Wirkus reassures nervous parents that serious side effects are "extremely uncommon. The most common are local reactions." He said one might feel like he or she was coming down with something, but illness doesn't actually occur.

Mark Lennihan, Associated Press
Girls play in a yeshiva schoolyard, Tuesday, April 9, 2019, in the Williamsburg section of New York. The city health department ordered all ultra-Orthodox Jewish schools in a neighborhood of Brooklyn on Monday to exclude unvaccinated students from classes during the current measles outbreak. In issuing the order, the health department said that any yeshiva in Williamsburg that does not comply will face fines and possible closure.

Lakin said many people get their information about vaccine risks from social media, "and they are not getting correct information anymore." Numerous studies have debunked alleged links between vaccines and autism, which originated from a now-infamous study by former doctor Andrew Wakefield, who lost his medical license after his work was shown to be falsified. Yet many people continue to believe Wakefield's initial claims that vaccines and autism are linked.

Wirkus notes an irony: Babies born with measles because they were exposed in the womb do have a higher rate of autism than those who weren't born with measles — related to having the disease itself, not the vaccine that's designed to prevent the disease.

Lakin acknowledges that bad physical reactions to vaccines are possible, but he notes they are very rare and rarely serious. He invokes the Harry Potter series by J.K. Rowling to explain the risk: In all seven books combined, there are about 1 million words. "If you go and pick one word from those books, that's your risk of getting a serious reaction to one of the vaccines," he said.

Nor is the question of vaccination exemptions being posed only in America.

The Council on Foreign Relations noted, “The World Health Organization (WHO) listed vaccine hesitancy as a top threat in 2019, and several countries are taking action to tighten immunization laws.”

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The council noted that every U.S. state requires vaccines related to attending school, but points out that many of them let parents "opt their kids out," granting a variety of exemptions. It said Washington and Minnesota are among states considering making it harder to opt out.

"Europe is having the same debate," the council said. "In the past two years, countries including France, Germany and Italy have tightened rules on childhood vaccines. The populist-led government in Italy vowed to overturn expanded vaccination requirements but reversed course after a surge in cases.”